Sunday, January 26, 2020

Benefits of Sustainable Water Management in Bangladesh

Benefits of Sustainable Water Management in Bangladesh Food security and surface water management has become a critical need in Bangladesh because of growing demand of food and water. With vision of enhancing food production and employment generation, Local Government Engineering Department (LGED) Bangladesh gets involved at local level surface water management in 1962. As an apex public organization, LGED performs overall planning and management of surface water at local level by confirming people participation. With past experience, LGED started participatory Small Scale Water Resources Development Sector Project (SSWRDSP) in 1995 and built about 580 sub-projects where stakeholders involvement in decision making process has become an integral part of sustainable development in surface water management. The purpose of the paper is to explore the potential contributions of sustainable surface water management in socio-economic development through food production and employment generation at the rural level. It reviews relevant external secondary data sources and internal SSWRDSPs which include sub-project based field data obtained for formulation, implementation, and performance evaluation of SSWRDSPs. Primary sources included extensive field visits, household survey and sub-project beneficiary and Water Management Cooperative Association (WMCA) interviews. Transcripts of field visit, field notes, and relevant literature are analyzed on the basis of themes, patterns and datas of interrelationships among those that addressed the research goal. To ensure true reflection, quantity and quality of data gets highest degree of priority. It is found that well-designed management of surface water resources is vital and essential in ensuring food security and rural employment. 1. Introduction Peoples in the developing countries are in emergency of essentials—food and water, shelter, energy and health although the scenario is quite opposite in the developed nations where the people are facing the difficulties of affluence (Roome, 2002).To attain the food demands of 2050, food production is needed to increase by 3 times. Historically agricultural production is the most suitable way of food production and only that can provide better diets for the people all over the worlds (Avery, 2002).To meet the controversy on the sustainable way of food production this paper tried to established that the participatory approach in surface water management is the most sustainable way of using surface water to increase agricultural production as well as the food production for the future. Now, sustainable food production as well as food for everyones is a global demand. A rising population of Bangladesh with declining agricultural land has put the countrys future food security at risk, especially when salinity in the coastal belt, and droughts and depleting underground water level in the north have become constant realities (Palma, 2010). According to a projection of the Bangladesh Bureau of Statistics the countrys population will be 170 million by 2020 (BBS, 2001; Population Council, 2010). Bangladesh currently has 8.44 million hectares of cultivable land, according to the Ministry of Agriculture. With 1 percent decrease of arable land due to building of new houses, industrialization, and urbanization the cultivable land area will come down to a little more than 7.0 million hectares in 2020 (MoA, 2007a). Bangladesh had to import nearly 2.0 million tons of food grains in the last fiscal year on top of around 30 million tons of rice and wheat produced domestically (Palma, 2010). These factors might lead to a decrease in productivity as was projected by the Inter-governmental Panel on Climate Change (IPCC, 2007). Though presently the situation of food security appears quite satisfactory, but the scenario was significantly different in past and also its future may not look the same due to increasing population and climatic changes. In 1971-1972 the area under rice production was 9,278.00 thousand hectare and the production was 9889.20 thousand metric ton (BBS, 2008). Due to different initiatives by the government through different organization such as Department of Agriculture Extension (DAE), Bangladesh Water Development Board (BWDB) and the Local Government Engineering Department (LGED) cultivable areas and production increasing day by day such as in 2005-2006 the rice production areas augmented into 10, 529.09 thousand hectare and the production increased into 24, 569.27 thousand metric ton (MoA, 2007b; BBS, 2008). Past experience can be argued that those achievement due to better surface water management preservation and use of surface water, training of farmers to address the depletion of underground water. Otherwise, it was and will be difficult to ensure food security for the ever increasing population (Palma, 2010). However, it is stated that Bangladesh faces some significant challenges in the next century. A combination of population growth, a reduction of arable land and the increasing living standards, will place pressure on food and water security in the country (Khoo, 2010). Brundtland commission (1987) stated that the sustainable food production is the production which should meet the needs and desire of the people without negotiating with the natural resource for the next generation (Roome, 2002). In this light, Participatory approaches in Integrated Water Resources Management (IWRM) for agriculture can be focused as the most sustainable eco-friendly farming as well as sustainable surface water management and food production system. The soil and Water Conservation Society of America stated that the Agricultural farming through surface water management is the most sustainable food production method as it has a unique capability of keeping the soil fertile without remarkable erosion by integrated management system (Avery, 2002). More steps for sustainable food production can be taken as the food production system does not create any negative impact on the environment (Heap, 2002). Moreover, in the face of rapidly changing national, regional and global ec onomic environment, Bangladesh agriculture is facing the challenge to reinvent itself to withstand competition and at the same time continue to provide food and employment opportunities for the vast majority of the population (MoA, 2006). 1.1 Local Government Engineering Department (LGED) and its Involvement The Local Government Engineering Department (LGED), whose origin dates back to the Rural Works Programme (RWP) initiated in the early 1960s, developed rapidly throughout the 1980s and 1990s. RWP was a component of the Comilla Model of rural development pioneered by the famous Aktar Hamid Khan at Bangladesh Academy for Rural Development (BARD) nationwide this was started in the early 1960s (Rahman, Rahman Rahman, 2007). In 1982 RWP switched to the Works Programme Wing (WPW) under the Local Government Division (LGD) of the Ministry of Local Government, Rural Development Co-operatives (MoLGRDC) (MoLG, 1982). Subsequently the administrative decentralization act of 1982 converted it into the Local Government Engineering Bureau (LGEB) in 1984 (MoLGRDC, 1984). With the needs for rural infrastructure development in the country and the readiness of LGEB to take on more responsibilities, LGEB was upgraded as the Local Government Engineering Department (LGED) in August 1992 (LGD, 1992). It is widely recognised that the role of infrastructure in economic development is significant and often greater than that of investment in other forms of capital (World Bank, 1994). Mujeri (2002) argues that rural infrastructure including irrigation structure play an important role in the socio-economic development of rural areas. Rural works Programme (RWP) and the Thana Irrigation Programme (TIP) and micro-finance have been seen as two interrelated sub-strategies for achieving poverty alleviation (MoLGRD, 1979; MIP, 1998). Comilla Model tried to integrate these two strategies and considered that the breakdown of the interrelationship between the RWP, the TIP and the co-operative would result in undermining of the whole rural development effort through the Comilla experiment (Sen, 1996). With mission and vision of Comilla model of A.H. Khan, LGED got involvement in escalating food production and facilitating food marketing through surface water management by excavating/re-excavating drains and canals, digging new canals, repair and construction of bunds and embankments, reclamation of land for productive purpose, repair and construction of bridges, repair and construction of earthen and pucca roads meant for irrigation and communication in the name of Works Programme and Thana Irrigation Programme (GoEP, 1962). The TIP program gave responsibility to the Union Parishad (UP) members to find out available surface water resources to plan for utmost irrigation coverage by Low Lift Pumps (LLPs). UP members formed project committees under the RWP to re-excavate irrigation canals for better agricultural production (GoEP, 1962). With the same objectives as of TIP, LGED started Canal Digging Programme (CDP) in 1979 initially on voluntary basis and later on with the assistance from Food for Work (FFW) to de-silt sediment filled channels all over the country to boost-up water storage capacity of channels for irrigation. The CDP aimed to increase irrigation water supply, drainage improvement, tree plantation on canal bank and fisheries development. The program implemented 3,276 km of khal re-excavation, 429,597 pond re-excavation projects and 382 hydraulic structures. The benefited area covered under CDP was about 419,500 hectares (IWRMU, 2008). In parallel to CDP, under Rural Employment Sector Programme (RESP) funded by SIDA and NORAD, LGED initiated development of small-scale water resources schemes to increase agricultural as well as food production and rural employment generation in 1986 and the programme was continued up to 1996 (MPIUS, 1998). The project implemented 60 small-scale schemes in six districts (Kurigram, Faridpur, Rajbari, Madaripur, Gopalgonj and Shariatpur). IDP covered about 20,530 hectares of cultivated land benefiting 51,230 farm families (RESP, 2000; IWRMU, 2008b). LGED has performed excellently in implementing the rural infrastructures in collaboration with local users to increase food production and consequent employment generation (Faruqee Choudhury, 1996). With an aim to provide dry season irrigation facilities by using surface water in increasing rice and non-rice crops production especially in the coastal belt LGED first implemented two rubber dams in Coxs Bazar District in 1995 on a pilot basis. Inspired by the success of the pilot projects, the Government considered rubber dams for wide replication and, consequently, construction of more rubber dams was taken up all over the country. LGED has constructed eleven more rubber dams in 1999-2007 (DoAE LGED, 2005) and started to construct 10 more rubber dams in 2009-2014. Participatory irrigation management and OM have been adopted for the rubber dam projects (DoAE LGED, 2009). 2. Objectives To surface the initiatives of the Local Government Engineering Department (LGED) in food security and employment generation through surface water management with participatory approach. To present the state of the art of the participatory surface water management process in sustainable socio-economic development by increasing crop as well as food production and thereby employment generation in the rural areas of Bangladesh 3. Methodology A detailed and systematic approach was followed to achieve the objectives of this study using two methods. First a broad review of external secondary data sources associated with the topic that included water and food production, irrigation, gender and development, employment generation, surface water management etc. and internal SSWRDSPs which includes the sub-project based field data obtained for formulation, implementation, and performance evaluation of SSWRDSPs were made. Pre-project data were compiled from sub-project appraisal reports while the monitoring and evaluation data were drawn from the Management Information System (MIS) unit of IWRMU, LGED and various project reports. Field information was fetched through befitting exercise supported by the SSWRDSPs and the IWRMU of LGED collected the post-project data after completion of the projects. Methodology of the study also involved two tier exercises. Firstly, information of the pre-status of the sub-projects areas were drawn from relevant published materials and field records and secondly the post-status of the sub-project areas from data obtained from MIS unit. Primary sources included extensive field visits, household survey and sub-project beneficiary and WMCAs interviews. Field workers of Non Governmental Organisation (NGO) were involved in the surveys and interviews. As the author is a fulltime employee of LGED and posted in the IWRMU as a Senior Assistant Engineer (Operation and Maintenance) and also in-charge MIS unit of IWRMU of LGED, got opportunity to involve in every steps of sub-project implementation cycle. Transcripts of field visit, field notes, and relevant literature were analysed on the basis of themes, patterns and datas of interrelationships among those that addressed the research goal. 4. Small Scale Water Resources Development Sector Projects of LGED Taking lessons from the performances of the earlier water resources development projects, LGED facilitates sustainable use of water resources with the participation of local stakeholders along with Local Government Institutions involving public and private sectors, communities and individuals in the implementation of Small Scale Water Resources Development Sector Project (SSWRDSP) to improve the socio-economic condition that includes food production and employment generation. The Project is implemented in conformity with the National Water Policy (NWP) that stressed integrated water management. The NWP has defined the role of the Local Government Institutions and given the mandate of implementing flood control, drainage and irrigation (FCDI) projects having command areas of 1,000 ha or less to increase the food production and employment generation (MoWR, 1999). The NWP states that water resources management requires involvement of the public and private sectors, communities and indiv iduals that benefit from the delivery of water-related services. Because, the ultimate success and effectiveness of public water resources management projects depends on the peoples acceptance and ownership of each subproject / project (MoWR, 1999). The first project was in the name of Small Scale Water Resources Development Sector Project (SSWRDSP) (1995-2002). The project aimed at sustainable growth in agricultural production as well as food production and incomes of about 140,000 farm families in western Bangladesh through the establishment of about 300 small-scale water resources development schemes (LGED, 1995). The phase-1 of SSWRDSP finally completed 280 subproject covering 165,000 hectares of cultivates land that benefits 142,000 farm families in 37 districts (IWRMU, 2008c).The main objectives of the Second Small-Scale Water Resources Development Sector Project (SSWRDSP) are to enhance agriculture and fish culture and to take effective steps in poverty alleviation through improving the surface water resources in different regions of the country (Rahman, Rahman Rahman, 2007). With the success and gathered experience from SSWRDSP-1 LGED started the 2nd phase of SSWRDSP covering larger areas in 61 districts of the country in 2003(LGED, 2001). The 2nd phase of the project is completed in 2010 (LGED, 2010a) and implements 300 sub-projects all over the country covering 163,000 hectares of cultivates land that benefits 154,000 farm families. The 3rd phase is started in 2010 in the name of Participatory Small Scale Water Resources Sector Project (PSSWRSP) and implementing throughout the country with an aims to develop 300 new sub-projects and for rehabilitation of 160 existing sub-projects (LGED, 2010b). It could be mentioned that another Small Scale Water Resources Development Sector Projects funded by JICA also implementing by LGED from 2008 covering 15 districts of greater Mymensingh, Sylhet and Faridpur having a plan to implement 300 sub-projects (LGED, 2010c). In implementing these projects, LGED is very much careful about participatory water management pro cess (MoWR, 2000). It has developed a very innovative framework of participation for addressing local peoples views in development initiative in water sector (LGED, 2009). The local people participate in all stages of the project cycle- identification and feasibility, design and institutional building, construction and first year OM (Operation Maintenance), sustainable O M and their participation is formulized through forming a Water Management Cooperative Association (WMCA) in each sub-project. After completion of the sub-project, the WMCA takes the responsibility of operation and maintenance of the subproject infrastructure (LGED, 2009). Capacity building of WMCAs is another important aspect of the project. Line agencies of the government imparted training to the WMCA members for their capacity building and LGED has signed memorandum of understandings with the agencies concerned (MoWR, 2000). Moreover LGED ensure the stakeholder participation to make the project effective and su stainable development as the interests of the community promotes a convergence among the government, development partners and other stakeholders, is considered as a key strategic step for sustainable investment (FAO, 2010). Monitoring of the completed 580 Sub-projects of the SSWRDSP shows increasing trend in cereal and non-cereal crop as well as food production. The increased crop/food production is due to increased cropping intensity in the subproject area and that intensity generates more employment in respective area. Evaluation of the project has been done by different agencies at different time. Bangladesh University of Engineering and Technology (BUET), Bangladesh Institute of Development Studies (BIDS) and WL I delft hydraulics, the Netherlands jointly evaluated the project. In addition Implementation Monitoring and Evaluation Division (IMED) under Ministry of Planning Bangladesh also evaluated the project and their findings are very much positive. In general, the evaluation agencies concluded that SSWRDSP has shown a very encouraging development in developing Socio-Economic conditions that includes food production and employment generation in the Sub-project area (BUET, BIDS delft hydraulics, 2 003; IMED, 2005). The project follows a participatory approach of implementation where local people play vital role in all stages of the project cycle. 5. Framework of participation The overall participatory process in subproject development adopted by the LGED is a combination of two parallel but interrelated processes: â€Å"Institutional† involving software elements and Technical involving hardware elements Sub-project implementation is participatory and the whole cycle of subproject development process is sub-divided into four distinct stages as presented below (Figure-1) (LGED, 2009). Stage 1: Identification and Feasibility In consultation with local stakeholders, the Union Parishad (Council) kicks off sub-project proposals. The LGED Upazila Engineer submits it to the Upazila Development Coordination Committee for approval. If approved, the proposal is forwarded to the Integrated Water Resources Management Unit (IWRMU) and to the Project Management Office (PMO) through the LGED Executive Engineer at the district level. IWRMU pre-screens the proposal during a multidisciplinary field reconnaissance. This is followed by (i) Participatory Rural Appraisal (PRA) and (ii) Feasibility Study (FS). Each subproject is reviewed and approved by District Level Inter-Agency Project Evaluation Committee (DLIAPEC). Stage 2: Design and Institution Building Following the approval of DLIAPEC, engineering design and establishment of Water Management Association (WMA) are done along with motivational awareness campaign among stakeholders. Process of establishing WMA is initiated under the legal framework of the Cooperative Societies Act (National Parliament of Bangladesh, 2001). Contracted NGO facilitator creates awareness, generates local enthusiasm in the local water resource systems, promote membership enrolment, assist in collection of beneficiary contributions, and conflict resolution. The WMA is registered with the Department of Co-operative (DoC) and becomes WMCA. The IWRMU undertakes engineering design work in consultation with stakeholders and discusses for their approval. This process concludes in the signing of a formal implementation agreement by the WMCA, Union Parishad and LGED Executive Engineer at district level before tendering for the works or contracting Labor Contracting Societies (LCS). To sign the implementation agree ment, the WMCA must have achieved (i) enrolment of at least 70% of beneficiary households; (ii) collection of beneficiary contributions equivalent to an annual OM requirement and deposited in a joint account by LGED and the WMCA; and (iii) approved plans in consultation with people-affected by the environmental mitigation and resettlement (land acquisition) (MoWR, 2000). Stage 3: Construction and First Year OM Civil works are tendered to contractor and earthworks awarded to LCS groups comprised of local landless, disadvantaged destitute males and females. The WMCA supervises construction through a 7-member committee trained on construction monitoring including one man and one woman from the concern Union Parishad (LGED, 2009). The WMCA forms OM sub-committee and prepares schedule, beneficiary list and maps, and plan comprising operating guidelines, and maintenance and resource mobilization plans. The IWRMU provides on-the-job training that helps WMCA to (i) undertake annual inspection, (ii) identify maintenance needs, (iii) prepare and implement annual OM plan, and (iv) collect OM fees. After observation of the infrastructures management performance during the first year of OM, the sub-project is handed over to the WMCA through a formal lease agreement with LGED (ADB LGED, 2009). The WMCA receives support of agricultural extension and fisheries departments to prepare agriculture and fishe ries development plans and to organize training for WMCA representatives who work as liaison extensions to beneficiaries (ADB, 2008). Stage 4: Sustainable Operation and Maintenance This stage starts after sub-project handover and continues throughout its lifetime. Continuous monitoring and support is provided by the IWRMU of LGED and other partner agencies. The WMCA and O M Committee receive regular training so that they are able to carry out O M of the sub-project. The WMCA Prepare O M Plan, Undertakes routine maintenance works and collects O M fees from direct beneficiaries in proportion to their land area benefited by the sub-project. (LGED, 2009) 6. Participation ‘Participation was first advocated in the context of development authorization in the 1950s due to failed development policies which were thought to lack integration of public concerns throughout their planning. Thus, participatory methods were encouraged as fundamental measures of development. In this process marginal groups (poor, women, indigenous and ethnic minorities) should come together with project authorities to share, negotiate and control decision-making processes (Lisk, 1981; WB, 1985). In each subproject of the SSWRDSP of LGED the organization in the name of WMCA is formed. The WMCAs play basic role to functionally represent beneficiaries in all processes of the sub-project cycle. The stakeholders participation is assessed by institutional and OM activities in the sub-project area. Institutional activities: Institutional activities are assessed by WMCAs functions. These include membership, beneficiarys contribution, capital formation and use and holding of meetings in each subproject. These are monitored quarterly through Upazila level Community Organizers (CO) and district level Socio-economist. WMCAs progress on institutional activities and their capability development in 580 subproject areas as monitored in December 2010 are as follows: WMCA membership: The WMCAs provide an excellent means to address the needs of a range of special interests. The membership in 580 WMCAs consists of 183,831 males and 70,723 females from an estimated total of 297,300 households. Average membership covers about three-forth of the total households. Women all over the world play an active role in agriculture, thus contributing to food security (IFAD, 2007). The WMCA members include marginal, small, medium and large farmers; landless; women and fishers. Women comprised one-third of the first management committee of each of the WMCAs and about 25% of the total membership as the National Policy for Womens Advancement, provides a significant commitments of the Government to equality of women and men which are also reflected in the national poverty reduction strategy that emphasizes the importance of womens rights and opportunities for progress in the battle against poverty (GoB, 2009; ADB, 2010). Each WMCA members elect a Management Committee with at least o ne-third women members. The Management Committee is supported by OM, agricultural, fisheries and credit management subcommittees. Regular Management Committee Meeting and Annual General Meeting are conducted by the WMCAs. Beneficiaryscontribution: the beneficiaries contribution construction of infrastructure in 580 sub-projects amounted (US$1,190.141) of which 89% was collected from the farmers beneficiaries of the water resources development. WMCA capital: These WMCAs have established a capital base in all sub-projects through shares and savings by the members. In 580 sub-projects, the capital accomplished well in excess of Tk 129.82 million (US$1,829). The capital is being used in supporting micro-credit, procurement of agricultural inputs, and other small-scale business enterprises operated by the individual WMCA. WMCAs have set up micro-credit programmess and have loaned to 26,900 male and 12,937 female members. The average size of each loan is about Tk 2,500 (US$ 366). Since the capital formation the cumulative investments of the WMCAs is Tk 110.1 million (US$1.55 million). The DoC inspects and audits the accounts of the WMCAs. The WMCA members have increased their income with investment of micro-credit on quality seed production, poultry farming, milking cow, beef fattening, vegetable production, aquaculture, seasonal crop storage, and grocery shops. WMCA capability development: The WMCAs members are given training to increase their capability in institutional management, capital formation, credit management, sustainable agricultural and fisheries production, improved farm practices, environmental management and subproject OM. Relevant departments and institutes support the project in training need assessments, course development, materials preparation and organisation. LGED has signed memorandum of understanding with the Department of Agricultural Extension (DAE), Department of Cooperatives (DoC), Department of Fisheries (DoF) and Department of Livestock Service (DLS) to support the subproject beneficiaries (LGED, 2006). The DoC supports subproject WMCAs in institutional strengthening and financial management. Field level official of DAE, DoF and DLS support the sub-project farmers and fishers in the preparation and implementation of agricultural and fisheries production plans and use of improved technologies. This has created opportunity for the integratio n and complementary of support services provided by the government departments and sustainable water resources uses for food production with the formation of cooperatives in the sub-projects areas. Three approaches are adopted to provide training to the WMCA members that included beneficiary farmers, fishers and women. The first approach is to identify and communicate with existing relevant programmes and to ensure that WMCA members have access to these programmes. The second approach is that where a need for a new programme is identified, the Project develops the material, testes it by conducting a number of programmes, and then transfers the training material to an appropriate institution. As an example, this is the approach used in establishing management training for the WMCA at the Bangladesh Academy for Rural Development. A third approach is used especially for new programmes. The Project works with the relevant institution to jointly prepare the curriculum and training materi als. The training is then delivered by that institution and further developed based on feed-back from participants and monitoring systems. This approach is used in the training delivered by the DAE Agricultural Training Institutes. General improvements during the course of the Project attributable to training impact were observed, in the nature of the institutional support provided to the local stakeholders, in the type of agriculture practiced within the Project area, in aquaculture, and in homestead food production patterns. All of these activities are imparted and monitored by IWRMU LGED. Operation and maintenance (OM)activities: The sub-project beneficiaries prepare annual OM plans and budget and mobilise local resources for the OM costs. LGED initiated extensive training programs for the WMCA OM sub-committee members to perform regular OM for the completed sub-project handed-over to them. The OM sub-committee is responsible for the preparation of annual plan and collection and utilization of funds for OM. Annually each WMCA collects OM fund from the farmers at the rate of 3.0% and 1.5% of the total cost for the subproject earthworks and hydraulic structures, respectively (ADB, 2008; ADB LGED, 2009). Table 1: Operation and Maintenance (O M) Budget (Taka-million) Budget 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 Subprojects No. 233 254 260 289 331 297 372 580 Contribution of GOB 2.99 7.39 15.89 20.48 22.25 24.39 30.73 47.5 Voluntary Labor Contribution 0.41 1.12 2.06 2.53 3.32 3.49 4.19 5.94 Total Collection (Taka) 3.4 8.51 17.95 23.01 25.57 27.88 34.92 47.5 % of voluntary contribution 12.1 13.2 11.5

Saturday, January 18, 2020

Common core skills Essay

The key areas in current legislation which relate to the safeguarding of children (1.1) .2.Evaluate the effectiveness of a range of activities that can be used to encourage children to protect themselves (1.2) 3.Explain at least 3 different types of transitions that children can experience over the age range birth to 16 years. Analyse the impact of the transition on children at a particular stage of development. (2.1 and 2.2) . Analyse the importance of play in supporting a child’s development.5. For this task you need to identify 3 play activities for children of different ages. We want you to evaluate their effectiveness, identify the materials you need, why you have chosen the materials selected and any health and safety implications. (3.1, 3.2, 3.3 and 3.4) 7. Why is it important that you consider the health and safety implications for both the play activity and the materials used? 9.When communicating with children you need to ensure that your communication is suitable for their stage of development. How can you do this? Please give examples in your answer. (4.2) .10.During your training you explored different communication methods. Select some of these methods and evaluate their effectiveness. (4.3) .11.Explain the main functions of a multi agency team. (5.1) .12.What are the benefits of a multi agency team? 13.Why do you, as a nanny, need to be aware of multi agency working and team working? (5.3) .14.As a nanny you may need to be working with a range of other professionals. How would working in this way ensure the needs of the child are met? (5.4) 15.Using the table below analyse which professionals you would need to be involved with and their role.

Friday, January 10, 2020

Macbeth’s diary

On the day that the battle had ended, I galloped through the misted heath on my valiant steed. Along side my trust worthy, noble partner Banpuo. The battle had been against the traitors of the king's victorious country. As I galloped I looked apon the heath as if it was my own. Our clothes dripped with the blood or the rebels. One clear image remains, an image of McDonald, and I, Macbeth, unseaming him from the nave to the chop. In the distance were three figures. As they became clearer I sensed that Banpuo became unsteady on his horse. As we continued the figures also continued to become clearer. The figures were not man or women. Not black or white. An expeditious decision led me to believe that the figures were witches. At that point I became uneasy on my steed as my fear grew. I stepped down from my horse closely followed by the brother I never had. Banquo gasped I breathed in deeply and stepped forward. He then asked how far isn't called to Forrest. He rapidly stepped back, I followed his eye movement and it was at that moment I realised that they were not to be taken lightly. Then as I stared in horror and a slight fear, Banquo began to speak. I then stood straight demanded for them to speak unless it was beyond their ability. They stepped forward and then they began to reveal themselves to us. They called upon me as my thane name. I lowered my head a little so that they would know that this was I. I looked at Banquo, he seemed to be as confused as I was. Then a second stepped forward. It also called out but this time of a different name. ‘Thane of Cawdor' is how they addressed me. So many questions went through my head. How Thane of Cawdor – he still lived. Then before I could ask myself any more questions, a third stepped forward to join the other two. Only this time it said, â€Å"All hail Macbeth! That shall be king hereafter!† Those words where the so exhilarating but at the same time I had so many questions. How? The king had two sons. I was no relation. But what if it was true how would it happen I could only think of one thing. No it will not happen. The only reason I met the witches was because I was on my back form a battle in which I had fought for king and country. Then I looked at Banquo; he then asked me why I seemed to fear. After he spoke this he stepped forward and wanted to know his destiny (if that was what they spoke of or maybe it is truth.) Then all three witches hailed Banquo but I was put to rest when they said â€Å"Hail Banquo lesser than Macbeth† I let out a sigh, â€Å"But then greater†. How greater than king. If I was to become king I knew that he couldn't be better than be as I had been greater than he had all of my life. Then the witch's started to drift away but they would not. I demanded for them to stop but no such reply did I get from the imperfect speakers. I was shocked yet all I could think about was why would Banquo's sons be king and not my own. I looked back at were my horse stood. I climbed upon my trustful steed and galloped deep into the heath with Banquo aside me. I recall the sound of footsteps. In front of us were Ross and Angus bringing news of the king's greatest gratitude. I was showered with praise then I heard what would be some of the most memorable words in my intire life. † And, for n earnest of a greater honour. He blade me from him call thee thane of Cawdor† Banquo yelled out in my presence â€Å"What can the devil speak true?† A thousand questions trust trough my mind. How, Why. The thane of Cawdor still lived. Was it a joke? No truth was spoken. I asked them why they dressed me in borrowed robes. They told me how he was under heavy judgement. I remember asking Banquo if he hoped that his children would be kings. As the first part of the devils words came true for me. I thought about the two truths that they spoke off. I was rapt. I felt as if I cleaved not to their mould. I wondered whether the message was good or bad. I had a very sudden thought. A horrid image or death and murder, evil. I was given the titles Glamis and Cawdor with out killing but then again king is a much greater title. I wanted to see the king maybe to remind myself of the good man that he was. I stirred, I was horrid, Banquo seemed to want to go but I was still very weary of what Banquo was feeling. I felt anxious to be king for it was always my dream it brought back memories and dreams that I once had to be king. Would they finally come true? Before I left I sent a letter to my dear wife telling her of my encounter with the witches and my thoughts about Banquo's supposed future. As Banquo and I fled into the castle accompanied by Ross and Angus, King Duncun labelled me worthy cousin. At this point in time I was overwhelmed with emotions. I was proud because the king of Scotland said that I as his worthy cousin. But also that it was another reason for me not to kill him after all being labelled a worthy cousin of the king is reward in its self. I was smiling but I couldn't help but wonder to myself if I was just pretending to like when I knew that it would only fill me with more contrition than I already had. I told Duncun of how I owed him everything and that doing it was a reward in itself. How could I lie to my king? I told him â€Å"Is to receive our duties; and our duties are to your throne and state, children and servants.† Then to my complete amazement he announced that he would be coming to my house for a feast. I was over come with astonishment. The king at my house it was such an honour but then after thinking that It was an honour I thought of how uncomfortable I would be knowing that I was thinking about, about murdering the king. Then with out anyone knowing he announced that his son was the new prince of Cumberland. This meant that he was inline to be the next king. So any hopes that I had of me getting the title without doing anything had disappeared. It was at this moment I felt more strongly but also scared about killing the king after all he was my king. The man who gave me such titles as, Thane of Glamis and Thane of Cawdor. As I left the room I tried to find something to hide my anger. So I looked to the stars and asked the solemnly, † Stars hide your fires! Let not light see my black and deep desires.† I wanted to be hidden so that all of my raging anger was concealed. Then I solidly remember what was going through my mind I was thinking and looking at my hand, the hand that might possibly kill the king of Scotland. I wrote a second letter to my wife telling her that the king was coming to our house but also some of my thoughts I didn't want to trouble her with all of them. As I set off the king told everyone to follow me and that I would bid them all welcome to my home. As we all arrived at my castle my wife greeted me not by darling or husband but as great Glamis and worthy Cawdor. This one a exceedingly special occasion for me because my meant so much to me that I felt so proud and just happy. Then I told her when Duncun was coming and when he would hence. As we began to talk about the letters, the witches and all of the happenings she began to seem determined and different in someway I can't explain how. The banquet was set for the king but I could not stay in the Kings Company. The guilt of my thoughts was too much. I was struggling with my conscience. I remember thinking that is I was to it, it would have to be done quickly with no hesitation. But he was a fair king how could I do it, he was such a gentlemen. I was his host I was surpposed to close the door on the murderers not bare the knife myself. If I were to do it there would be tears all over the kingdom and everyone would mourn his death. How could I do it to such a dear and well thought of man? My wife came to speak to me and asked why I left the banquet, I didn't answer, I just wanted to know if he had asked for me. She said no but she also started to insult me because I told her that we would not proceed any further in the business. She was using language that she of all people knew would agitate me no end. I told her to stop but she wouldn't if I was to do. This then I would a monster. I tried to be the best that I could be but for some reason it was only now I felt as if it was insufficient. Then I began to wonder what had changed as she said, â€Å"Be so much the man†¦. I have given suck, and know how tender't is to love the babe that milks me.† Had she really changed or was she just trying to shock me into the action. Either way I felt as if it was working. But what if we should fail? My doubts grew yet as she answer they all began to dissolved like a drug in water. I began to feel as if my wife was stronger than I was. I was just filled with a feeling of confusion. Then out of nowhere she suggested to blame the guards that would lay outside the king's chamber. Then I told her that she should only give birth to males. I couldn't kill him; she must have seen my doubts in my expressions because once again she began to attack my manhood. Then putting my entire disbelief aside I settled on the decision that I would do it I would kill the king of Scotland. I would kill him but until then I would be like a flower hiding the great serpent. As I walked through the long corridors that seemed never ending, I recall seeing Banquo and his son Fleance. I felt so much guilt for the intense concoctions that brewed in my mind. When Banquo informed me of his dream about the witch's I was overwhelmed with guilt for lying to such a pure man. As I left Banquo I proceeded along the long and winding corridors, a fatal vision appeared before my eyes. Could the mind create such a false vision? I said to myself. As I looked closer it seemed to resemble a dagger of my own. I reached for my dagger grasping it but never taking my eyes of the dagger. Then I tried to grasp it but to my own amassment my hand went straight through it. It began to move, so I followed it my heart pounding like the drums at a beheading. I was short of breath and my mouth was completely dry. Whilst I was following the knife I realised that it was leading me to the king's chamber. I felt as if the witches were there, that they were influencing me but I still decided to follow the dagger. I felt that on a night such as the one that night there was evil in the air. Then out of nowhere gouts of blood appeared on the dagger dripping from the tip. This disturbed me because even though I have seen lots of blood before never the kings. I felt like a ghost, almost invisible as I walked through the passages getting closer to the King's room. All of a sudden the bell that invited me to Duncun's murder chimed. The bell of Duncun's death called me. I looked out of the and then for the first time taking my eyes of the bloody dagger. I peered out of the window and found myself lost in thought. I was sweating and was very hot I went into the room were the king lay asleep and the deed was done†¦ Then suddenly I heard footsteps I felt uneasy and quit scared. My mouth became dry once again and my palms became very sweaty. Then my wife appeared I was breathing heavily. With two bloodstained daggers in my hands. I told her that the deed was done. I began to hear things. I was extremely effected by the murder that I had committed that I had forgotten the instructions that my wife had given me. As I had still had the bloodstained daggers in my hand which dripped the blood of Duncun. I told her that I was never going in there again. I just couldn't go back in the room were the king had died, were he was murdered, by me. Her anger was immense she quickly took them from me and followed her own instructions. I remember feeling and knowing that I would be dammed for this dishonourable crime that committed. I was looking at my hands so red so wet†¦ so bloody. Such a sight will remain in my mind forever! I heard one of the guards screaming murder! He was saying prayers. I was so frightened. I was sweating; I could feel the river flowing down my back and trickling down my forehead down to my nose then into my mouth the salty sensation almost took my mind of the murder. Only to be interrupted by my oh so changed attitude from my wife. It was remarkable; I didn't know that someone so close to me, someone who I had known for so long could change so quickly and considerably. I would sleep no more. I felt so scared that I would never sleep or even be able to rest again. I could never of thought that this murder would effect me this much but it did and that in itself confused me. I was indescribable fear. No words can say what I was going through. It was the worst moment of my life. Suddenly there was knocking at the door, which gave me a fright, I yelled with no hesitance, â€Å"Wake Duncun with thy knocking! I would thou coulst!† I regret saying this, and then my wife dragged out me away. As I walked down stairs in a fresh set of cloths Macduff and Lennox were there. Macduff asked me if Duncun was awake, so I took them to Duncun as we walked Lennox and Macduff kept on asking me questions. Each time I was filled with dread and deep remorse. Almost every sentence from my mouth was a lie. Then we arrived at the door; I was the only one there who really knew what was inside. Macduff went inside the room, whilst Lennox and I stood outside. He was telling me about the weather last night, he was taking about hearing screaming and strange things happened. I was being eaten from the inside. Macduff ran out of the chamber and screamed â€Å"O horror! †¦ Horror! †¦ Horror!† We both asked what he was talking about, I felt expectant, and I was just waiting for him to say it was Macbeth who killed him but he didn't. Lennox was confused but I knew what he meant. We went into the room and we looked around. Outside I could hear Macduff shouting things like, † Ring the alarm bell!†¦ Murder and treason!† Everyone was outside so I killed the guards and made it look like an act of anger when I did this I thought that it would take the focus from me but to Macduff it just made it worse. He asked my why I did it, I thought that he was suspicious, I told him that I couldn't help it and that I was so angry that I saw the blood on them and their daggers that I just lashed out. My dear wife then fainted, I think she did this because she knew that I was not up to talking to anyone at the moment and I might have broken down. Then Banquo said something unforgettable to me, â€Å"And question this most bloody piece of work to know it further.† I knew that he would be suspicious. He thought that there was more to his death. This made me very worried I thought that I had very good reason. I thought that I was finished. I mean he was there when I met the witch's. Then with good reason the two sons of the king Donalbain and Malcolm fled the country afraid of their own lives. So I, Macbeth, was crowned the new king of Scotland my coronation was brief but for filling I was proud of myself even though I was not proud of what I did to do it. Then came the day after my egotistical coronation. I felt so much better because I was organising a banquet to celebrate my coronation. I saw Banquo in the morning and questioned what he was doing for the day. I told him that I wanted him to come to the banquet. Banquo and Fleance left for a day of hunting. I spoke to the rest of my men and told them that they could have the rest of the day of until seven o'clock when they would all attend the banquet. As everyone but one of my many servants left the room, I told my servant to fetch me those men. As I was left alone I began to speak to myself and re assure myself that I had to do this to keep my crown safe and that I needed to be done if I wanted to keep my crown. He was the competition he would produce a long line of kings, inless I stopped him and to do that I would have to kill him and his son. For the first time I felt determined but I also felt something's that had been frequent in my feelings like fear and anger. If I wouldn't keep the crown then it was fruitless. I was not willing to let that happen so I decided that when the murderers got back I was to give them the go ahead, to kill Banquo and Fleance. My servant and two murderers came through the door. I didn't want to speak with them for long so I just told him that Fleance's death was just as important as Banquo's and that it must be done far away from the palace also that it was to be done that very same night. Even th ough I was swamped with guilt and anger I also knew that it had to be done. I didn't tell my wife, I locked her out because I had a feeling that she wouldn't be able to deal another murder. I went to see her; she was my clueless wife. I was trying to protect her, I told her, â€Å"Thou know'st that Banquo and his Fleance lives.† Something would be done when the darkness came then I would be jocund. Then I left her to get ready for my Banquet to celebrate that I became king. The Banquet was ready everyone had arrived accept for Banquo, I walked swiftly into the room and the atmosphere was like no other. Everyone stood up and applauded me. This was the proudest moment of my intire life†¦ king such an achievement, I thought it could only be dreamed about until that moment in time. As my lords who were once my fellow fighters stood up I looked around but did not see Macduff. But at that moment in time I want bothered. I could feel my jaw aching from the full smile on my face. I looked around and saw a spare seat upon my men and lords so I walked over and sat with them. I did this so that they would think of me as a peoples king, a good king. As I began to sit down. Lurking in the doorway was one of the murderers walked over to him and said, † There's blood upon thy face!† To my greatest satisfaction he told me that it was Banquo's blood. I told him that it is better on him than inside Banquo. He told me of how he slit his throat. Relief ran through my veins. But before I got to excited I asked about his, but there was no such luck to be had there. He notified me that he had run away. I was filled with dread something had to be done but what I didn't know what. I was filled with complete horror I was shocked, mortified and extremely troubled. I melted into as much fear that was in my bones when I committed the murder of Duncun. As I turned round I tried my best to be strong; I fled back to the spare seat only to be greeted by the cold corps of Banquo. All I could do was shout which one of you has done this? â€Å"What my lord?† They were totally clueless; I reacted to the goast almost screaming at it, Thou canst not say I did it! . . . Never shake thy gory locks at me! My wife then whispered to me, â€Å"Are you a man?† I told her that I was but a bold one, she kept answering back so I told her to look and behold. Then the ghost disappeared, I told her victim's appered with twenty mortal murders on their crowns, and push us from our stools. This was stranger than such a murder was. Then I spoke to my company and told them not to look mutely at me. Then the ghost reappeared at first I didn't see it but when I did I quickly reacted by yelling avaunt and quit my sight! Let the earth hide me. The reason that I remember so much about it is because it was such an ugly sight that I will never forget what I had to say to him or it. My wife lied to my guests telling them that I was ill. Then I carried on shouting, screaming trying to scramble to safety in my mind. It disappeared so I said †¦why so †¦ being gone. I was still unaware that only I could see the ghost, I was speaking to my guests but I don't remember what I was saying. Ross then said, â€Å"What sights, my lord?† It was only now that I finally realised that only I could see the ghost, my wife told everyone to leave us and Lennox told me to have better health. After everyone had left I told my wife that there was no going back and that I would be punished for this. I decided to go back the witch's, I am determined to know what's going to happen to me next. I knew that I had to find out what was to come and if it was worse than had already come. Before I left I asked if she had noticed if Macduff was at the banquet that started of to be a celebration. She said no, so I began to worry about his suspicions and why he wasn't there. Having found no conciliation or help I decided to go to bed and then in the morning return to the heath where it had all started. After a restless night, I had decided to go to the heath to find the witch's. As I arrived at the heath upon where we had first met I saw the hags and addressed them for what they were. When I called them old hags it was to try and show them that I had more power than they did. I soon realised that they were not afraid when then replied, † A deed without a name.† This worried me slightly, I remember thinking what I was thinking trying to overpower such evil. I demanded to know what was coming I educated them with what I had to say. Then I told them that I demanded them to see their masters and not hear from them. As I was waiting the flashes of lightning and the lions roaring from above shocked me. Then all of the witches chanted, † Come high or low, thyself and office deftly show.† It was at this moment that I knew that I was going to find out what my future was. Then suddenly, out of the cauldron arose an armed head and spoke, † Macbeth! Macbeth! Macbeth! Beware Macduff!† I had come to the heath looking for good news, some informative information but so far all I had got was confirmed suspicions. I said a quick thank you and asked them to know more and to tell me of it. â€Å"He will not be commanded. Here's another more potent that the first.† One of the witches's quickly announced. Then another image appeared from the cauldron called on me just as the first but then said, † Be bloody, bold and resolute. Laugh to scorn the power of man; for none of women born shall harm Macbeth.† Why should I fear, all men are born of a woman then why should I fear? It was at this point I began to wonder if I was immortal, if I was blessed with the gift of ever lasting life. I will remember those words for as long as I shall live. Then I had an outburst and shouted and then live Macduff. What need I fear? But just in case I was to have him killed I remember feeling such relief, joy, delight, I had renewed bravery and a new spirit. Then another apparition arose from the cauldron and it was a child, crowned, with a tree in his hand. At first I remember not knowing what it meant so I asked the witch's what it was, they told me to listen but not to speak do I did and only to find out the best news so far. It said that I would not vanquish until the great Birnam wood moves. This only confirmed my suspicions about being immortal. Then the cauldron began to disappear and the next eight kings of Scotland appeared all resembling and carrying Banquo's spirit. I screamed out to the witch's and interrogated them on why they showed me this. Before I could ask them anything else they danced and vanished. All of a sudden Lennox appeared startling me, I asked if he had seen the hags, he replied with a simple no. Looking back I don't remember all that he said but I did hear the sound that triggered my anger and my fear, which was that Macduff had fled to England. This meant that I couldn't kill him. So instead I went to his ca stle were I was to kill his wife and babes. So of we went to the castle. I told all of my attendants not to bring me anymore reports that I didn't care, until the wood moves I shall not fear. I remember that no matter how many times I said it I didn't fear, if anything it made me stronger. I felt so succour, so safe and strong. Not just my heart but my mind, for the first time in a long time. I was interrupted by one of my servants, he informed me that there were English soldiers in their thousands. I began to realise the depth in which I had sunk. I called in my chief officer, Seyton, and I told him to tell me what was happening with the English. He said â€Å"All is confirmed, my lord, which was reported.† At this I recall asked him to bring me my armour, but he then went on to saying that it was not needed yet. I turned to my doctor and asked him how the patient was referring to my wife. He then said that she wasn't so sick but she did see fancies that stooped her from sleeping. I wanted it all to just go away, my wife did not deserve to not sleep. I did the deed so I should be punished. She did nothing so why was she suffering so much? Then I shouted out that I would no fear till the wood of Birnam wood come to Dunsinane. I met with my soldiers to tell them that I did not fear that they would not starve me out. I could feel my strength and my security. Then I heard an ear piecing scream from above, I had almost forgotten the taste and smell of fear itself. I was told that it was my wife's cry. This made me feel like falling to my knees. But I couldn't deal with it; the English soldiers were coming. After doing everything I now have no one to share it with no one. Then one of my servants rushed in and I told him that I didn't want to hear it. But still he told me, â€Å"I looked towards Birnam and anon the wood began to move. I screamed liar slave! I remember being in extreme anger and disbelief. Then I went with the messenger to see for myself and when I did I felt a shiver down my spine I began to doubt the witch's. Still with some respect left I took all my strength and went to the gate with my amour on to face the fiends. The alarms where sounded and I appeared to show my face to Macduff. I wasn't afraid of him because no man could kill me so I told him and the answer was not so nice as the question he told me that he was ripped from his mothers whom. This made me scared, the witch's had tricked me into thinking that I was immortal and that no man could kill me. But I was not a coward I told Macduff that I would fight only to lose. We fought our heavy swords dragging us down. I felt as if every muscle was being dragged out of my body and then Macduff drew his sword at me for one last time and†¦

Thursday, January 2, 2020

Infertility Polycystic Ovary Syndrome - 1113 Words

Infertility: Polycystic ovary syndrome is probably the most common cause of anovulatory infertility (11), associated with an increased risk of miscarriage after either spontaneous or assisted conception (1) and the development of ovarian hyperstimulation syndrome (OHSS) in assisted conception (12). A higher incidence of first trimester spontaneous abortions (25–73%) has been reported in women with polycystic ovaries or PCOS (13). Abnormalities in LH secretion were found in 81% of women with recurrent fetal loss, and higher androgen levels were observed in women who had recurrent miscarriages, both with and without PCOS. Anovulatory infertility, due to arrested folliculogenesis in PCOS, is frequently found in association with insulin resistance (IR) and obesity (14). A series of intraovarian growth factors [insulin-like growth factors (IGF), AMH, growth differentiation factor 9 (GDF-9) and inhibin] and extra-ovarian factors (GH, IGF-1 and insulin) seem to act together in a process that triggers anovulation or early pregnancy loss through the impairment of folliculogenesis, oocyte maturation, steroidogenesis and endometrial receptivity but whether these abnormalities are the direct cause of anovulation and pregnancy loss, or the consequence of deranged steroidogenesis has to be determined (15). Whereas underweight is associated with poor fetal growth and increased pregnancy loss, overweight is more strongly associated with diseases in pregnancy, pregnancy loss, stillbirth andShow MoreRelatedInfertility, Insulin Resistance, Polycystic Ovary Syndrome and Myo-Inositol1814 Words   |  8 PagesPolycystic ovary syndrome is an endocrine disorder that affects at least 10% of women living in the United States. Insulin Resistance plays a large part in fe rtility for women who have polycystic ovary syndrome. Myo-Inositol improves fertility, and alleviates many of the symptoms associated with polycystic ovary syndrome and insulin resistance. Polycystic ovary syndrome is a condition that affects many different parts of the body, not just the ovaries. The list of ailments associated with polycysticRead MoreA Brief Note On Low Grade Inflammation And Cardiovascular Disease1498 Words   |  6 Pagesobsessive-compulsive, interpersonal sensitivity, depression, aggression and psychoticism scores in comparison to health matches. Investigators concluded that PCOS significantly increased the risk for psychological morbidity (McCook et al., 2014). Infertility is a hallmark indicator of PCOS, and is often in initiator of diagnosis. Women who are unable to conceive from PCOS experience a significant decrease in quality of life (McCook et al., 2014). Person Women of reproductive age are at risk for developingRead MorePolycystic Ovarian Syndrome : Etiology- Environmental And Genetic Factors782 Words   |  4 PagesPolycystic Ovarian Syndrome: Etiology- Environmental and Genetic Factors Literature in NFS Seminar 4601 Fall 2015 Ashley Anger Date of Submission: 11/25/15 Introduction: The condition Polycystic ovary syndrome(PCOS) is the most common of endocrine disruptions within women of reproductive ages. The disorder does affect as much as 10% of women within this reproductive lifecycle. The clinical and biochemical features of the condition are diverse and are as follows: fertility disruptionRead MorePCOS Essay1152 Words   |  5 Pagesrecent years that effects women’s health is Polycystic Ovarian Syndrome (PCOS). 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Polycystic ovarian syndrome has many related symptomsRead MoreA Brief Article On Ovary Syndrome ( Pcos )1654 Words   |  7 PagesPolycystic Ovary Syndrome (PCOS) By Navodita Maurice | Submitted On September 01, 2011 Recommend Article Article Comments Print Article Share this article on Facebook Share this article on Twitter Share this article on Google+ Share this article on Linkedin Share this article on StumbleUpon 1 Share this article on Delicious Share this article on Digg Share this article on Reddit Share this article on Pinterest Expert Author Navodita Maurice The endocrine disorders among females are of variousRead MorePcos1874 Words   |  8 Pagesï ¿ ¼ Polycystic Ovary Syndrome Dr. Sqouras Christal Alfonso Burhan Sadiq In this research paper I will attempt to discuss the causes, symptoms and signs of Polycystic Ovarian Syndrome, as well as how it is diagnosed and treated. As someone who is suffering from this disease, I found my research to be very informative and educational, raising awareness for my own understanding, and it is my intention to ensure that this same awareness is translated in my research paper. What is Polycystic OvarianRead MoreInfertility : A Common Endocrine System Disorder Among Women Of Reproductive Age1568 Words   |  7 PagesInfertility due to Polycystic Ovarian Syndrome Infertility affects close to 6.1 Million US women during the reproductive age (7). What is infertility? Infertility is generally defined as â€Å"the inability to conceive after 12 months of unprotected sex. After the age of 35 pregnancy becomes more difficult and if infertility persist a shorter timeframe of six months is recommended (2). Infertility is not an illness it is a disease. 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